Increased intracranial pressure in a case of spinal cervical glioblastoma multiforme. Analysis of these two rare conditions

Atypical Presentation of Glioblastoma Multiforme

Background

Glioblastoma multiforme (GBM) is a highly malignant glial tumour classified by the World Health Organization (WHO) as a stage IV astrocytoma. It varies in shape and size and can be cystic, vascular and necrotic. It often appears as a ring-enhancing lesion on magnetic resonance imaging (MRI). The most common symptoms of GBM, such as headache, vomiting and seizures, are due to increased intracranial pressure. The objective of this case report is to describe an atypical presentation of GBM.

Case Report

A 53-year-old woman of Italian origin presented with a 2-week history of lack of coordination in her hands and some difficulty in speech. Electromyography for assessment of her arms and cranial bulbar function was normal. However, 2 days later, the patient presented to the emergency department with progressive weakness in her left arm and leg as well as difficulty in speech. Mild left facial asymmetry was noted. A brain MRI revealed a right frontal mass. Stereotactic surgical resection was performed 2 days later, and biopsy confirmed the diagnosis of GBM. Although headache and other features of raised intracranial pressure are the most common initial symptoms of GBM, any atypical neurological or psychiatric presentation in an adult patient should raise suspicion for this tumour.

Conclusion

Careful analysis of an adult with atypical signs and symptoms along with thorough review of radiological tests will facilitate early diagnosis of dangerous tumours such as GBM.

LEARNING POINT

Rapid progression of glioblastoma multiforme: A case report

Glioblastoma multiforme (GBM) tumors are intracranial lesions with varying shapes that grow rapidly. GBM tumors most commonly present as solitary lesions and multiple lesions are rare. The aim of the present case report was to investigate the imaging features of glioblastoma multiforme (GBM). In this study, the case of a 60-year-old patient who was hospitalized due to seizures is presented. Magnetic resonance imaging (MRI) revealed multiple lesions, heterogeneous in size, with peritumoral edema and ring-shaped enhancement. The lesions grew rapidly within 10 days of hospitalization and were initially misdiagnosed as either infections or intracranial metastatic tumors as a result of imaging examinations. The patient was subsequently administered mannitol, diazepam, Tegretol and ceftriaxone. After treatment, the patient recovered and regained full consciousness. However, MRI examination 23 days after hospitalization revealed that the multiple lesions in the left temporal and left occipital lobes had increased in size. Therefore, resection of the tumor in the left temporal occipital lobe was performed. Histopathological examination identified GBM (grade IV) in the left temporal and parietal lobes. The patient succumbed to the disease 7 months after surgery due to GBM recurrence. The findings of the present case indicate that GBM may progress rapidly with a doubling time of 10 days and multiple cystic alterations. Furthermore, if diagnosis of GBM is unclear, early biopsy is recommended.

Glioblastoma multiforme - an overview

Glioblastoma multiforme is a central nervous system tumor of grade IV histological malignancy according to the WHO classification. Over 90% of diagnosed glioblastomas multiforme cases are primary gliomas, arising from normal glial cells through multistep oncogenesis. The remaining 10% are secondary gliomas originating from tumors of lower grade. These tumors expand distinctly more slowly. Although genetic alterations and deregulations of molecular pathways leading to both primary and secondary glioblastomas formation differ, morphologically they do not reveal any significant differences. Glioblastoma is a neoplasm that occurs spontaneously, although familial gliomas have also been noted. Caucasians, especially those living in industrial areas, have a higher incidence of glioblastoma. Cases of glioblastoma in infants and children are also reported. The participation of sex hormones and viruses in its oncogenesis was also suggested. Progression of glioblastoma multiforme is associated with deregulation of checkpoint G1/S of a cell cycle and occurrence of multiple genetic abnormalities of tumor cells. Metastases of glioblastoma multiforme are rarely described. Treatment of glioblastoma multiforme includes tumor resection, as well as radiotherapy and chemotherapy. Drugs inhibiting integrin signaling pathways and immunotherapy are also employed. Treatment modalities and prognosis depend on the tumor localization, degree of its malignancy, genetic profile, proliferation activity, patient's age and the Karnofsky performance scale score. Although the biology of glioblastoma multiforme has recently been widely investigated, the studies summarizing the knowledge of its development and treatment are still not sufficient in terms of comprehensive brain tumor analysis.

Compression stiffening of brain and its effect on mechanosensing by glioma cells

Many cell types, including neurons, astrocytes and other cells of the central nervous system respond to changes in extracellular matrix or substrate viscoelasticity, and increased tissue stiffness is a hallmark of several disease states including fibrosis and some types of cancers. Whether the malignant tissue in brain, an organ that lacks the protein-based filamentous extracellular matrix of other organs, exhibits the same macroscopic stiffening characteristic of breast, colon, pancreatic, and other tumors is not known. In this study we show that glioma cells like normal astrocytes, respond strongly in vitro to substrate stiffness in the range of 100 to 2000 Pa, but that macroscopic (mm to cm) tissue samples isolated from human glioma tumors have elastic moduli on the order of 200 Pa that are indistinguishable from those of normal brain. However, both normal brain and glioma tissues increase their shear elastic moduli under modest uniaxial compression, and glioma tissue stiffens more strongly under compression than does normal brain. These findings suggest that local tissue stiffness has the potential to alter glial cell function, and that stiffness changes in brain tumors might arise not from increased deposition or crosslinking of collagen-rich extracellular matrix but from pressure gradients that form within the tumors in vivo.